Sexual and reproductive health and rights: A position paper pptx

Millions of women and men lack access to contraception and to the sexual and reproductive health information and services they need to choose their family size and improve their own and

Sexual and reproductive health and rights

A position paper

Cover photo: Two women harvest vegetables from their plot in Kenya Two babies sleep

Sexual and reproductive health and rights

A position paper

Published by the Department for International Development

July 2004

by the Rt Hon Hilary Benn MP

Secretary of State for International Development

Sexual and reproductive health is important to us all, at all stages of our lives Yet far too many

people are denied their right to sexual and reproductive health The vast majority are poor women,

men and young people in developing countries

Millions of women and men lack access to contraception and to the sexual and reproductive health

information and services they need to choose their family size and improve their own and their

children’s life chances Millions more people are living with HIV and sexually transmitted infections

that could have been prevented or treated Every minute a woman dies from a complication of

pregnancy or childbirth Some 80 million women each year have unintended or unwanted

pregnancies For too many their only option is abortion in unsafe conditions Women, especially, need

more choice and control over their sexual and reproductive lives

There have been some gains But not enough progress has been made since the 1994 International

Conference on Population and Development agreed the goal of reproductive health for all by 2015

This will make attaining the Millennium Development Goals much harder

We intend to keep at the forefront of the international debate on controversial issues and to support

country governments and partners to uphold everyone’s right to sexual and reproductive health

These rights have their opponents who feel threatened by them and we must therefore continue to

explain why they are important and relevant to everyone

This paper complements the UK’s Call for Action on HIV and AIDS, DFID’s strategy on maternal

mortality and our Target Strategy Papers on ‘Better Health for Poor People’ and ‘Realising Human

Rights for Poor People’ We will use it as the basis for action and work with our partners, and I hope

you will find it useful

Hilary Benn

July 2004

Chapter 4: What progress has been made? 15

Improving access to sexual and reproductive health services 19

Addressing social, cultural and economic barriers to 20reproductive health

Generating and applying knowledge 21Chapter 6: Conclusion: Where do we go from here? 22

Sexual and reproductive health is a human right, essential to human development and to

achievement of the Millennium Development Goals DFID is firmly committed to the Programme of

Action of the International Conference on Population and Development and will continue to support

governments and partners to achieve reproductive health for all by 2015

Poor people, especially women and young people, face huge social and economic barriers to sexual

and reproductive health 120 million couples do not have access to the family planning services and

contraception they need Every year, 529,000 women die from complications of pregnancy and

childbirth and 3 million children die in the first week of life 38 million people are currently living

with HIV and 340 million people contract sexually transmitted infections each year Most are

preventable

This paper sets out DFID’s position on Sexual and Reproductive Health and Rights and our view of

the future It forms the basis for planning our investment and activities and our work with partners

We have seen considerable achievements since the I994 International Conference on Population and

Development set goals and targets on reproductive health and rights for all by 2015 Countries have

turned ICPD commitments into policies and action, increased access to a range of family planning

options, and in some countries cut maternal deaths But faster progress is needed We face new

challenges, in particular the devastating impact of HIV and AIDS and the biggest ever population of

young people entering their reproductive years Demand for sexual and reproductive health services

and commodities will continue to grow Health systems remain weak in many countries, and are

deteriorating in some There are too few health workers particularly in the poorest areas We could

make more use of opportunities to integrate HIV and sexual and reproductive health services in ways

that respond better to people’s needs

DFID will work with country governments and partners to:

• advocate internationally and nationally for policies and resources that address people’s rights

to sexual and reproductive health, and continue to address controversial issues such as safe

abortion and harmful and coercive practices;

• improve access to comprehensive services, that are responsive to the rights and needs of

poor people and other vulnerable groups;

• address social cultural and economic barriers, using a rights-based approach, and tackling

issues outside the health sector; and

• support research, monitoring and evaluation and apply knowledge and lessons learnt in

policy and planning

Our aim is to achieve the following outcomes:

• Improved maternal and newborn health

• Accessible, high quality family planning choices

• Elimination of unsafe abortion

• Reduced incidence of HIV and sexually transmitted infections

• Greater awareness of sexual health and reduced risky behaviour

• Gender equality, rights, accountability and equity realised everywhere

Summary

Chapter 1

1 The goals of the International Conference on Population and Development (ICPD) of 19941,2

provide the foundation for many of the Millennium Development Goals We have seen real progress

towards the target it set of universal access to reproductive health services by 2015 Important gains

have been made over the last decade in sexual and reproductive health and rights, with a renewed

focus on women’s needs But there are threats to these gains and much more work to be done to

meet the goals and targets

2 This paper reviews and updates DFID’s position on sexual and reproductive health and rights

The following sections review the current situation, describe challenges ahead, and set out DFID’s

view of the future We will use the paper as the basis for planning our continued contribution to

achieving the ICPD goals It also communicates to our partners our continuing commitment and

approach to achieving those goals

Why are sexual and reproductive health and rights important?

3 Sexual and reproductive health is an essential element of good health and human

development But we need more progress on sexual and reproductive health to meet many of the

Millennium Development Goals (MDGs), particularly those concerned with child and maternal health,

HIV and AIDS and other communicable diseases, and gender equality Better sexual and reproductive

health will also accelerate progress towards the MDGs on eradicating extreme poverty and hunger,

and achieving universal primary education

4 Upholding people’s rights to sexual and reproductive health would help meet the MDGs in

many ways Most maternal and newborn deaths could be prevented by improved access to

well-integrated reproductive health services, including antenatal care, skilled attendance during childbirth

and immediately after birth, and emergency obstetric care for complications Family planning and

modern contraception offer choice and opportunity for women to make informed decisions and have

more control over their lives Enabling young women to avoid pregnancy too early in life, when they

are at much greater risk of complications, reduces maternal and child deaths Better spacing of births

reduces child mortality and improves maternal health Sexual and reproductive health information

and services are essential to efforts to prevent HIV and AIDS

5 Sexual and reproductive health is also important as an issue in itself People have the right to

make their own choices and decisions, based on sound information Improving sexual and

reproductive health is among the most cost-effective of all development investments, reaping

personal, social and economic benefits It will save and improve lives, slow the spread of HIV and

AIDS and encourage gender equality It will help to stabilise population growth and reduce poverty

Reducing high fertility can create opportunities for economic growth if the right kinds of social

policies are in place.3

6 Reproductive rights must be protected, promoted and fulfilled if sexual and reproductive healthoutcomes are to be improved, particularly for the poor and vulnerable A rights perspective highlightsthe importance of empowering people to take their own decisions about their sexual and

reproductive lives It strengthens the ability of poor and vulnerable people to demand and useservices and information and to be heard It also puts emphasis on equitable access to services andwomen’s empowerment

7 Experience shows that, given the choice, people want the benefits that sexual and reproductivehealth offers The increased choices and opportunities, especially for women, that come from betterand more accessible sexual and reproductive health services and education, have led millions ofpeople in many countries to opt for smaller families But huge inequities remain The poorest peoplehave the most to gain from improved access but are least able to use and benefit from availableservices Priority, clear goals and resources for sexual and reproductive health are needed withinPoverty Reduction Strategies and other development plans

What do we mean by sexual and reproductive health and rights?

8 ICPD defined reproductive health as:

“a state of complete physical, mental, and social well-being and not merely the absence

of disease or infirmity, in all matters relating to the reproductive system and to its functions and processes”.Men and women should be able to enjoy a satisfying and safe sexlife, have the capability to reproduce and the freedom to decide if, when and how often to do

so This requires informed choice and access to safe, effective, affordable and acceptablehealth-care services

9 And reproductive health care as:

“the constellation of methods, techniques and services that contribute to reproductive and sexual health and wellbeing by preventing and solving reproductive health problems It also includes sexual health, the purpose of which is the enhancement of life and personal relations and not merely counselling and care related to reproduction and sexually transmitted diseases”

10 Reproductive rights are defined in the ICPD Programme of Action paragraph 7.3, and are

based upon rights recognised in international human rights treaties, declarations and otherinstruments, including the International Covenant on Economic, Social and Cultural Rights, theInternational Covenant on Civil and Political Rights, the UN Convention on the Elimination of AllForms of Discrimination Against Women (CEDAW), the UN Convention on the Rights of the Child,

Chapter 1 Introduction

1

and the International Convention on the Elimination of all Forms of Racial Discrimination The 2004

UN Commission on Human Rights explicitly recognised women’s sexual rights as essential to

combating violence and promoting gender equity ICPD and ICPD+5 underlined the importance and

contribution of rights to population, reproductive health and gender equality issues The 2001 UN

General Assembly’s Declaration of Commitment on HIV and AIDS reinforced the ICPD commitments

on sexual and reproductive health needs and placed a strong emphasis on women’s empowerment

ICPD recognised that people’s sexual and reproductive health needs are rights that they are entitled

to demand Box 1 lists specific rights relevant to sexual and reproductive health

Box 1: Specific rights relevant to sexual and reproductive health4,5

• Right to the highest attainable standard of health.

• Right to life and survival.

• Right to liberty and security of person.

• Right to be free from torture, cruel, inhuman or degrading treatment.

• Right to decide freely and responsibly the number and spacing of one’s children and to

have the information and means to do so.

• Right of women to have control over and decide freely and responsibly on matters

related to their sexuality, including sexual and reproductive health, free of coercion,

discrimination and violence.

• The same right of men and women to marry only with their free and full consent.

• Right to enjoy the benefits of scientific progress and its applications, and to consent

to experimentation.

• Right to privacy.

• Right to participation.

• Right to freedom from discrimination (on the basis of sex, gender, marital status, age,

race and ethnicity, health status/disability).

• Right of access to information.

• Right to education.

• Right to freedom from violence against women.

Sexual and reproductive health and rights: A position paper

of reproductive age (15-44 years) and some 14 per cent for men.6These figures may underestimatethe full burden as they exclude menstrual disorders and some respiratory tract infections Of allhuman development indicators, those for sexual and reproductive health reveal the largest gapsbetween low income and developed countries and the starkest inequities between rich and poorpeople within countries.

12 Each year, an estimated 210 million women become pregnant.7Of these, 8 million experiencelife-threatening complications related to pregnancy and many more develop long-term physical andpsychological ill health and disabilities More than half a million women die every year duringpregnancy and childbirth from complications that can almost all be treated effectively A woman’slifetime risk of dying due to maternal causes is one in 16 in sub-Saharan Africa, one in 94 in Asia,and one in 160 in Latin America, compared to one in 2,800 in developed countries.8Despite somesuccess stories, the global maternal mortality ratio has changed little over the past decade DFID’sstrategy on reducing maternal deaths describes the problem and what can be done to improvematernal health in more detail.9

13 Some 80 million women face an unwanted or unplanned pregnancy each year.10Larger thandesired family sizes can make it harder for households to escape poverty and jeopardise thenutrition, health and education of children Reproductive health and family planning offer a way toimprove life chances, yet in developing and transition countries, more than 120 million couples arenot using any contraception despite their expressed desire to avoid or to space future pregnancies.About 45 million women seek abortion,1119 million of them in unsafe circumstances Unsafeabortion kills 68,000 women every year, accounting for 13 per cent of all pregnancy-related deaths.Unsafe abortion is also associated with considerable ill health, including infection and infertility.Forty per cent of all unsafe abortions are performed on young women aged 15 to 24 years Almostall these deaths and illness could be prevented through improved access to and choice in sexual andreproductive health services, particularly family planning and contraception to enable plannedpregnancy Safe comprehensive abortion services can also help eliminate deaths among women who

do seek abortion because of lack of choice or control over the circumstances in which they becomepregnant In all settings, effective post-abortion care should be a part of routine services

14 Many of the 3 million deaths each year of babies in the first week of life12and 2.7 millionstillbirths are related to poor health of the mother and to inadequate care during pregnancy,childbirth and the period immediately after birth These statistics have not changed in developingcountries in the past 20 years Short birth intervals risk the lives of children and mothers Survey datafrom 18 countries suggest that, compared with children born less than 2 years after a previous birth,children born 3 to 4 years after a previous birth are 1.5 times more likely to survive the first week of

life and 2.4 times more likely to survive to age five.13Postponing first births until the mother is at

least 18 years old is another important factor in reducing child deaths There is also evidence that

short birth intervals increase the risk of death for the mother.14

15 340 million new cases of largely treatable sexually transmitted bacterial infections occur

annually,15100 million of them among young people Many go untreated due to difficulties in

diagnosis and lack of access to competent, affordable services Many of these infections increase the

risk of HIV transmission

16 The terrible toll of HIV and AIDS is clear: 38 million people living with HIV of which 25 million

are in sub-Saharan Africa.16In the worst affected countries 1 in 4 people may be infected, with rates

of infection still rising Of these 38 million people 17 million are women, and 2 million are children

infected through mother-to-child transmission Fifteen million children have already lost one or both

parents to HIV and AIDS, and it is estimated that there will be 18 million orphans in Africa by 2010

Fewer than 1 in 5 people at risk have access to prevention information and services The UK

Government Strategy on HIV and AIDS17describes the problem and response in more detail More

could be done through better integration of services for HIV and AIDS and sexual and reproductive

health so that they are complementary and not competitive

17 Failure to uphold various rights in law, policy and practice adds to the barriers that poor

women and men face in accessing services and information and adopting healthy behaviours For

example, sometimes women may not be offered contraception without their husband’s consent

Millions of women have no power to challenge violations of their rights Mechanisms for redress are

rare There is strong evidence from work on HIV and AIDS that fulfilling the rights to freedom from

discrimination and to privacy leads to markedly better prevention and treatment.18The challenge

remains of how better to apply the human rights principles of participation, inclusion,

non-discrimination, fulfilling obligation, accountability, and entitlement in and beyond the health sector,

in ways that make a real difference to people’s lives

18 Gender discrimination and other forms of social exclusion have very direct effects on sexual

and reproductive health They increase vulnerability to HIV and other sexually-transmitted infections,

particularly amongst younger girls and women Social restrictions, lack of financial security and

decision-making power in the household, lack of inheritance and property rights, and inequitable

access to education earlier in life, all limit women’s use of services and ability to adopt healthy

sexual and reproductive behaviour Programmes often lack components that address such issues

Sexual and reproductive health and rights: A position paper

19 Violence against women exists across all socio-economic groups throughout the world, andincludes a wide range of violations of women’s rights, including forced prostitution and trafficking,child marriage, rape, wife abuse, sexual abuse of children, intimidation in the workplace, and harmfulpractices and traditions (including female genital mutilation) that damage sexual and reproductivehealth It also includes coercive family planning (e.g forced sterilisation) Violence is a major cause oflong-term gynaecological and psychological problems, unsafe sex, unintended pregnancies, resort tounsafe abortion, maternal deaths, miscarriages, still births and low birth weight babies.

20 Young people are particularly vulnerable to problems of sexual and reproductive health This iswidely recognised but too rarely translated into accessible services for young people The poorestwomen start their childbearing youngest, between the ages of 15 and 19 in many developingcountries Half of new HIV infections are among young people aged 15-24, many of whom remainignorant of the epidemic or ill prepared to respond In some African countries more than half ofyoung people do not believe they are at risk.19Prevalence is highest among young women and girls.The 15 million children so far orphaned by HIV and AIDS will be particularly vulnerable and less likely

to complete schooling

21 The focus on women and young people should not neglect the role of men and their ownhealth needs The damaging effect of sexually transmitted infections, unplanned pregnancies andother sexual and reproductive health problems on the lives of women and men cannot be fullyaddressed without men Men often lack access to the information and services they need to protecttheir partners’ and their own sexual and reproductive health, including education and counselling,diagnosis and treatment of sexually-transmitted infections, and contraceptive services Men may play

a damaging role in controlling women’s and young people’s sexual and reproductive behaviour andtheir access to services and information

22 Demand for reproductive health commodities is increasing as populations grow, and as peoplebecome more knowledgeable and actively seek out family planning, and condoms for protectionagainst sexually transmitted infections as well as for contraception Yet millions of women and menare unable to access the contraceptives and related services they need to plan when and if to havechildren Meeting the current gap and future increases in demand will make a huge difference topeople’s lives It will lower reliance on abortion, which for many women is the sole means ofregulating fertility The number of couples wanting contraceptives is predicted to rise from 525million couples in 2000 to 742 million in 2015 UNFPA also predict that the need for condoms forprevention of HIV and other sexually-transmitted infections will rise from 8 billion in 2000 to 12.8billion in 2005 and 18.6 billion in 2015.20Improving the supply of commodities will require bettercoordinated systems nationally and internationally for needs assessment, financing, procurement,regulation and distribution

Chapter 2 What is the scale of the problem?

2

23 Poor sexual and reproductive health and huge unmet need for family planning is threatening

wider development, especially in Africa Here, while average family size is falling in many places,

populations are still growing and so the effect of individual women having fewer children is offset by

increasing numbers of women of reproductive age Three quarters of women in sub-Saharan Africa

need but do not have access to family planning and the opportunity it offers to take more control of

their lives UN projections show an increase in Africa’s population from 794 million in 2000 to 2,000

million in 2050.21This huge increase is almost bound to check progress towards poverty reduction

goals and achievement of the MDGs

24 Health service coverage in many high burden countries is currently far short of meeting needs

for services for sexual and reproductive health This is particularly so for poor people and other

underserved groups, including displaced people and refugees In many countries, institutions are

often weak and financing inadequate to cope with even the most basic needs, let alone increasing

demand for reproductive health services Shortages of human resources for health are being made

worse in countries hard hit by the HIV epidemic

Sexual and reproductive health and rights: A position paper

• responsive and accountable to poor and vulnerable people;

• appropriate to local needs;

• acceptable to poor women, men, young people and specific vulnerable groups

(such as sex workers);

• affordable;

• physically accessible (location and opening times);

• of high quality (client-focused, well-managed with the skilled staff, equipment and supplies

needed to offer best practice); and

• non-discriminatory and non-stigmatising (attitudes of health providers to poor and

vulnerable people)

26 As for so many other aspects of basic health, improving reproductive health depends onstrengthening health systems Increasing access to sexual and reproductive health services requiresadequate resources (both financial and human), accountability between policy makers, providers andcitizens, and strengthened public institutions The critical shortage of service providers and otherhuman resources for health calls for both short and longer-term responses to problems such as lowpay and poor incentives, migration, deployment and retention – as part of wider strengthening ofservice delivery systems Building effective demand for sexual and reproductive health servicesmeans commitment to giving poor people more say and improving their ability to hold providersaccountable for the delivery and quality of services Community-based and community-led actionalso provides an important and essential part of the response and drive to promoting better sexualand reproductive health

27 There are significant barriers to behaviour change experienced by young people Abstinencemessages have been promoted as a way to promote behaviour change However, evidence seems tosuggest that simply telling young people to abstain is not the answer.22WHO studies show that sexeducation delays the onset of sexual activity and increases safer sexual practice.23They need theknowledge, skills and assertiveness to make safe decisions and have them respected, including to say

no and to delay sex Research shows that sex education does not increase the number of sexualpartners among young people.24They need access to comprehensive and confidential services that